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A nurse is reviewing discharge instructions with a client following a right cataract extraction. Which of the following instructions should the nurse include?
- A. Sleep on the abdomen to facilitate wound healing.
- B. Bend at the waist to pick objects up from the floor.
- C. Notify the surgeon if white drainage develops on the eyelids.
- D. Avoid lifting anything heavier than 4.5 kg (10 lb) for 1 week.
Correct Answer: D
Rationale: Lifting heavy objects can increase intraocular pressure, disrupting healing post-cataract surgery. Avoiding heavy lifting is critical. Other options risk complications or are unnecessary.
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A nurse is caring for a client who has Meniere's disease. The nurse identifies which of the following manifestations is caused by an excessive accumulation of endolymph fluid?
- A. Myopia
- B. Vertigo
- C. Photophobia
- D. Presbycusis
Correct Answer: B
Rationale: Vertigo is a primary symptom of Meniere's disease, caused by excessive endolymph fluid in the inner ear affecting balance and spatial orientation. Myopia, photophobia, and presbycusis are unrelated to endolymph accumulation.
A nurse is preparing a plan of care for a client who is postoperative following a cochlear implant insertion. Which of the following instructions should the nurse include in the plan of care?
- A. Lie on your back when sleeping.
- B. Wash your hair 24 hr after surgery.
- C. Resume your exercise routine.
- D. Eat foods that are soft
Correct Answer: D
Rationale: Soft foods are recommended to avoid strain on the surgical site, reduce the risk of dislodging packing or stitches, and promote comfort during initial healing. Lying on the back is not necessarily required unless specified by the surgeon. Hair washing within 24-48 hours post-surgery risks infection. Exercise is typically restricted initially to prevent strain on the surgical area.
A nurse is providing teaching to a client who has neutropenia. Which of the following information should the nurse include in the teaching?
- A. Avoid crowds
- B. Eat plenty of fresh fruits and vegetables
- C. Take temperature weekly.
- D. Perform mild exercise, such as gardening
Correct Answer: A
Rationale: Neutropenic patients are highly susceptible to infections. Crowded places increase the risk of exposure to pathogens. Fresh fruits and vegetables can harbor bacteria, posing a risk for infection in neutropenic individuals. Neutropenic patients should monitor their temperature daily, not weekly, to detect infections early. Gardening can expose individuals to soil-borne organisms that could lead to infections.
A nurse educator is working with the staff to decrease skin tissue injuries to clients on the medical surgical unit. Which of the following practices will decrease friction injuries?
- A. instruct the client to dig their heels into the bed to push themselves upwards.
- B. Assist the client with a trapeze to raise their body while staff assists with repositioning
- C. Have two to three staff members pull the client up in bed when needed.
- D. Elevate the head of the bed 90° for bedridden clients.
Correct Answer: B
Rationale: Using a trapeze reduces friction and shear forces during repositioning, preventing skin injuries. Other options increase friction or shear risks.
A nurse remains with a client to observe for any adverse reactions after initiating a transfusion of packed RBCs. The client becomes apprehensive and tachycardic, reporting headache and low back pain. The nurse should recognize that these findings indicate which of the following transfusion reactions?
- A. Hemolytic
- B. Allergic
- C. Febrile
- D. Bacterial
Correct Answer: A
Rationale: Acute hemolytic reactions present with fever, chills, headache, low back pain, tachycardia, and apprehension due to red blood cell destruction, requiring immediate intervention.